BURNS

Elizabeth Farr, Medical Student

Background
Comprise 1% of the workload of A + E departments1

90% can be managed without referral to a regional burns

unit1
Types of burns: Thermal
Scald Contact Flame Inhalation

Chemical Electrical Radiation

Pathophysiology
THERMAL BURNS have: Local effects Immediate irreversible tissue loss Area of hypoperfusion which may be salvageable **Loss of skin = fluid loss + infection + loss of thermoregulation

Systemic effects if burns > 30% of BSA CVS Capillary permeability Peripheral + splenic vasoconstriction Reduced cardiac contractibility Respiratory Bronchoconstriction + ARDS Metabolic Basal metabolic rate increases by 3 Immunological Reduced immune response 2

History
Important to determine potential associated risks, but dont delay resuscitation! How did it occur? How long was there contact for? Was any first aid carried out at home? Child protection issues

For fires Was it an enclosed space? (CO poisoning, smoke inhalation) What was the burning material? How long was the patient exposed to fire + smoke? How did they escape? (risk of additional injuries) Any loss of consciousness?
Past medical history Tetanus status

Assessment
ABCDE approach

Check response Call for senior help Remove all clothing + jewellery + cover with clean sheets Assess for risk of C Spine injury (explosions, jumping out of a window to escape fire) + apply collar

AIRWAY Have any hot gases been inhaled?

Hx of fire, soot in oral/nasal cavity, singed nasal hair, hoarse voice, stridor,

dysphagia, facial burns

Upper airway obstruction can develop hours after trauma so arrange

for a flexible laryngo/bronchoscopy if in doubt Give High flow Oxygen Involve anaesthetists early Consider early intubation

BREATHING
Exclude life threatening chest injuries Circumferential chest burns need escharotomy Is there a risk of CO poisoning?

Hx, may have cherry red skin, arterial blood gases, COHb level Give 100% Oxygen

CIRCULATION
IV access two wide bore cannula can insert through burnt skin if

necessary Bloods Cross match, FBC, U & E, glucose, coagulation Vital Obs BP, Cap refill, UO, Pulse, RR Provide early analgesia (IV morphine + cyclizine if major) Fluid resuscitation necessary if burns cover >15% body surface area in adults, or 10% in children or the elderly Use a burns calculator or formula PARKLAND = 4 X weight (kg) X % burn = mL of crystalloid/ 24hours Give 1st half over 8 hours from time of injury Other formulas include MUIR + BARCLAYS Check clinical response + urine output (insert a catheter)

Assessing Extent - Size

Ignore erythema

As a rough guide for adults remember the rule of nines Head + Neck = 9% of total body surface area Each arm = 9 % Each leg = 18% Front of torso = 18% Back of torso = 18% Perineum = 1%
*Also as a rough guide the patients hand covers about 1% of BSA)* For children < 10, or for a more accurate (but time consuming) guide use LUND & BROWDER CHARTS

Site
Sites that need special consideration + referral to a burns

unit
Airway Hands Feet Perineum Face Eyes Circumferential limb burns vascular compromise

Depth
SUPERFICIAL (1st or 2nd Degree burns)

Erythema Blistering Blanches with pressure Painful

DEEP PARTIAL THICKNESS (2nd degree burns)

Red + white Painful Bloody blisters Does not blanch with pressure

FULL THICKNESS (3rd degree burns)

White, brown, or black and May look leathery Do not blister Painless Requires excision

Severity
Major > 25% of BSA or any inhalation injury Need referral to a burns after initial resuscitation

Moderate
10 % of BSA Need fluid resuscitation and may need to be seen by a specialist OR any special sites or atypical injury Need referral to a burns unit due to cosmetic/functional

complications

Minor
<10% of BSA

MANAGEMENT
Principles of all burns: RESUSCITATION Fluid replacement Analgesia Reduce complications: Infection Scarring Loss of function

Major Burns

Resuscitation Do not cool with cold water as this can worsen shock IV Morphine + cyclizine Cover burn with cling film or dry sterile sheets Do not apply dressings until assessment by a burns specialist Refer to a major burns centre (Chelsea & Westminster) Ensure tetanus prophylaxis

Other burns that need referral to a specialist (Surgery, ITU or burns):

Special sites+ inhalation injury Children (unless superficial) Burns > 10 % (need admission for fluid replacement + analgesia + future

surgery) Significant full thickness burns (surgery will almost definitely be required) Chemical, Radiation, Electrical burns Any co-morbidities, trauma, special social needs

Smaller burns
Comprise partial thickness <10% TBSA or full thickness < 2% Many are managed at home with simple first aid
Cool with cold water + appropriate dressing

Leave full thickness burns uncovered as they will need to be assessed

by a specialist Do not de-roof blisters from partial thickness burns but may aspirate Chemical burns = copious irrigation with water
Clean and cover with an appropriate dressing Advise that burn will need to be reassessed and the dressing will need

to be changed after 48 hours (at GP surgery) Analgesia NSAIDS Warn of signs of infection (some centres give topical antibiotics) Tetanus prophylaxis

Any questions?